Trust Board Meeting in Public: Wednesday 11 July 2018 TB

Transcription

1 Trust Board Meeting in Public: Wednesday 11 July 2018 Title Integrated Performance Report: Month 2 Status History For information. The report provides a summary of the Trust s performance against a range of key performance indicators as agreed by the Trust Board. Board Lead(s) Ms Sara Randall, Acting Director of Clinical Services Key purpose Strategy Assurance Policy Performance

2 Executive Summary 1. In June 2018, 1,191 patients waited for over four hours from arrival to admission, transfer or discharge from OUH s Emergency Departments. This was 390 fewer than in May and Trust s four-hour wait performance improved from 88.63% in May to 91.08% in June. 2. No patients waited over 12 hours from a decision to admit to admission in April, May or June. 3. Numbers of beds occupied began to reduce in mid-may but staffing shortages and associated temporary bed closures have meant that bed occupancy remains high. 4. On 31 May 2018, 7,555 of 52,657 patients on incomplete elective care pathways at OUH were waiting for over 18 weeks % of people awaiting planned care were waiting for less than 18 weeks. 6. Over 52-week waits in Gynaecology grew from 152 in April to 162 in May. Another 25 patients were waiting for over 52 weeks for treatment in other specialties. 7. Four cancer waiting time standards were not met in April, including 31 days to first treatment and waits for subsequent surgery. Loss of operating theatre capacity puts future delivery of the surgical wait standard at risk unless mitigating action is taken. 8. Performance on the six-week standard for diagnostic waits was outside the national standard in May 2018 at 2.52%, with particular pressures in MRI, Audiology, Myocardial perfusion scans (Cardiology) and Cystoscopy. 9. The national standard for VTE assessment was met in May, as was the standard for providing care for inpatients with stroke on a dedicated stroke unit. Recommendation 10. The Board is asked to receive the Integrated Performance Report for Month 2. _IPR_ M2 Page 2 of 18

3 Integrated Performance Report: Month 2 (May 2018) 1. Key Headlines on Performance 1.1. RTT Incomplete performance was 85.65% in May, up 0.4% on April Over 52-week waits in Gynaecology grew from 152 to 162 and 25 patients were waiting for over 52 weeks in other specialties Diagnostic wait performance worsened to 2.52% of patients waiting for over six weeks in May, breaching the 1% national standard for a third month Last-minute cancellations affected 0.74% of elective admissions in May % of patients cancelled were not rebooked within 28 days well below the 36.36% in January but still above the 5% experienced in December In April, four cancer waiting time standards were not met, including 31 days to first treatment and waits for subsequent surgery. Loss of operating theatre capacity puts future delivery of the surgical wait standard at risk unless mitigating action is taken There were 68 newly-acquired category 2, 3 or 4 pressure ulcers in OUH care during April During May: There were no cases of MRSA bacteraemia There were 6 cases of Clostridium difficile % of inpatients received a VTE risk assessment, maintaining OUH performance above the 95% standard which has been met since December % of patients with acute stroke spent at least 90% of their time on a stroke unit, below the 100 achieved in April but above the national 85% standard There were no nationally-reportable breaches of the single-sex accommodation standard In June 2018, 1,191 patients waited over four hours from arrival to admission, transfer or discharge from OUH s Emergency Departments. The Trust s four-hour wait performance improved again to 91.08% During June, no-one waited for over 12 hours in the Emergency Department from a Decision to Admit to admission, though 230 waited 4-12 hours for admission (down from 269 in May). _IPR_ M2 Page 3 of 18

4 2. Cancer Overall position on national cancer standards 2.1. Four of the eight national standards were not met in April 2018, the latest month for which data are available. This represented a distinct worsening of performance on both 31 day and 62 day waits to first treatment and a worsening of waits for subsequent surgical treatment. Pressure was also evident on the two week wait standard which was not met nationally, but it was met at OUH Performance by month since January is shown below, with April s figures shown against those for NHS England. Table 1: OUH performance against national cancer standards and England comparison Standard At least 93% of patients referred from a GP with suspected cancer will be seen within 2 weeks of referral. At least 93% of patients referred from a GP with breast symptoms but not suspected cancer will be seen within 2 weeks of referral. At least 96% of patients will receive first definitive treatment within 31 days of a decision to treat. At least 85% of patients will receive their first treatment within 62 days of referral from a GP. At least 94% of patients will receive subsequent treatment with surgery within 31 days of decision to treat. At least 98% of patients will receive subsequent treatment with anti-cancer drug regimen within 31 days of decision to treat. At least 94% of patients will receive subsequent radiotherapy within 31 days of a decision to treat. At least 90% of patients will receive their first treatment within 62 days following referral from a screening service. OUH performance England Jan-18 Feb-18 Mar-18 Apr-18 Apr % 95.70% 97% 95.65% 95.06% 90.8% 93.0% 100% 94.90% 96.97% 93.43% 84.3% 96.0% 93.60% 97.50% 98.51% 92.96% 97.3% 85.0% 81.90% 81.40% 81.31% 80% 82.3% 94.0% 95.20% 95.40% 100% 93.14% 94.3% 98.0% 100% 100% 98.00% 98.50% 99.3% 94.0% 97.30% 98.20% 97.88% 98.20% 97.1% 90.0% 97% 90% 94.34% 83.30% 88.3% _IPR_ M2 Page 4 of 18

5 First definitive treatment within 31 days of a decision to treat 2.3. Of 341 patients receiving first definitive treatment in April 2018, 24 waited for longer than 31 days, performance of 92.96%. This was double the number of breaches in March Performance by tumour site is shown below, illustrating improvement in Head & Neck and Lower GI, but a worsening of waits in Urological. Table 2: Performance by tumour site: beginning first definitive treatment within 31 days of diagnosis Tumour site OUH performance England Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 Apr-18 Breast 100% 98.0% 100% 100% 100% 100% 98.4% Head & Neck 80% 91.7% 86.2% 95.7% 91.3% 100% Lower GI 100% 100% 97.1% 96.7% 100% 96.9% 97.5% Lung 87% 96.2% 83.3% 100% 92.9% 94.4% 97.7% Skin 97.7% 100% 100% 100% 100% 98.3% 98.0% Urological 92.8% 89.1% 90.6% 95% 92.1% 82.6% 95.2% First treatment within 62 days of a GP referral with suspected cancer 2.5. In April 2018, of 165 referrals for which OUH was accountable, 33 did not receive their first treatment within 62 days of urgent referral from a GP % of patients therefore received their first treatment within 62 days The number of people who received first treatment for cancer in April following GP referral is shown below by time group. Within 31 days 32 to 38 days 39 to 48 days 49 to 62 days 63 to 76 days 77 to 90 days 91 to 104 days After 104 days Following an agreed protocol, any cancer patient waiting for over 104 days for treatment has a review conducted of potential for clinical harm from the delay and details are reported to the Clinical Governance Committee on a quarterly basis Comparison with the England position on key tumour sites is given below. Most breaches took place in the Urological, Lower GI, Gynaecological oncology, Head & Neck and Lung tumour site groups. Percentage performance compared poorly with England in Lung and Lower GI in particular. Table 3: 62-day breaches by tumour site and % receiving first treatment within 62 days of urgent GP referral with suspected Tumour site group Nov- 17 Dec- 17 Jan- 18 Feb- 18 _IPR_ M2 Page 5 of 18 Mar- 18 Apr- 18 % <62 days Apr-18 England Apr-18 Breast % 93.8% Gynaecological Haematological Head & Neck Lower GI % 72.3% Lung % 71.8%

6 Tumour site group Nov- 17 Dec- 17 Jan- 18 Feb- 18 Mar- 18 Apr- 18 % <62 days Apr-18 England Apr-18 Other % 74% Sarcoma Skin % 95.7% Upper GI Urological % 79.5% All cancers % Subsequent treatment with surgery within 31 days of decision to treat Seven of 102 patients receiving surgical care for their cancer in April waited more than 31 days from decision to treat. Of these seven, five waited for up to 38 days, one for up to 48 days and one for up to 62 days The availability of staffing for operating theatres at the Churchill Hospital is having an impact on the number of sessions available for cancer surgery and the Surgery and Oncology Division has proposed the development of elective surgical capacity at the Horton General Hospital to release theatre capacity at the Churchill and help mitigate the otherwise continuing risk to providing cancer surgery within the 31 day standard. First treatment within 62 days of screening service referral This standard was not met in April. Four patients began treatment after 62 days of referral, with all starting treatment within 76 days of referral. Reporting As reported to the Board in paper TB , changes have been made to the system used by NHS England to report on cancer wait standards. This involves being able to report on the 38 day handover date for care responsibility between two providers OUH has been ready to report on this new basis in time for April 2018 and has done so. NHS Improvement has since advised the Trust that national delays mean that the new method of breach reporting will apply from figures for October 2018, which will be published in December Analysis of existing breaches has indicated that the new method of breach allocation should be expected to worsen OUH s reported performance. 3. Diagnostic Waits 3.1. Diagnostic wait performance worsened to 2.52% of patients waiting for over six weeks, breaching the 1% national standard In May, a total of 12,662 people waited for diagnostic tests, up from 11,903 in April but very similar to the 12,497 in March. 319 people waited for over six weeks, up from 206 in April Waits of over six weeks were concentrated in MRI (114 patients, 3 over 13 weeks); Cardiology echocardiography (where the delays are waits for myocardial perfusion scans due to the availability of isotopes, with 86 patients waiting for over 6 weeks and two for over 13 weeks); and Audiology (58 patients, one over 13 weeks). _IPR_ M2 Page 6 of 18

7 4. Urgent Care and Four Hour Waits Performance 4.1. In June 2018, 1,191 patients waited over four hours from arrival to admission, transfer or discharge from OUH s Emergency Departments, continuing the reduction seen since March. The Trust s four-hour wait performance improved to 91.08%, bringing it above the trajectory level for the month agreed with NHS Improvement though still below the national standard of 95% Emergency admissions ran at an average of 218 per day in June, well above the 207 per day in June 2017 and the 211 per day in April Total attendances ran at 445 per day in June 2018, similar to the 448 per day in May The GP streaming service at the John Radcliffe treated 499 attendances in June, all but two within four hours During June, there were (on average) 40 breaches of the 4 hour standard per day, compared to 51 in May and 55.5 in April fewer per day would have been needed to achieve 95% In June: No waits were reported of over 12 hours in OUH s Emergency Departments from a Decision to Admit people (a mean of 13.6 per day) waited for over four hours and were discharged without being admitted. These non-admitted breaches have accounted for 35-40% of breaches in recent months and were 37% of breaches in May people waited for 4-12 hours for admission after a decision to admit. This averaged eight patients per day. The equivalent figure in March was Children and young people accounted for two over-4 hour waits in June, well below the mean of 8.25 breaches per day in May People classified as Minor attendances (not requiring multiple investigations, imaging or interventions such as resuscitation) accounted for a mean of less than one breach every two days Non-admitted breaches tend to occur in the evenings and early mornings and analysis of these waits is informing staffing proposals for the Emergency Departments on both sites. Maintaining such waits at a significantly reduced level will be a crucial part of sustaining improved performance on the 4 hour standard Delayed transfers of care affected 49 patients at the end of May 2018, down from 74 in April. 2,106 bed days were used by delayed patients at OUH during the month, down by 127 bed days (5.6%) from April The chart below illustrates improvement since March in the number of 4 hour waits per day and in waits following a decision to admit. _IPR_ M2 Page 7 of 18

8 Figure 1: Emergency activity and waiting times, January June 2018 (Source: monthly reports to NHS England) hr trolley waits / day 12hr trolley waits >4hr waits / day Attendances / day Emergency admissions/day 0 0 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 4 hour trajectory The trajectory agreed by Executive Directors and sent to NHS Improvement is as follows. Table 4: 4 hour wait trajectory for OUH, 2018/19 (planned figures in shaded cells) 4 hour waits Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 1,890 1,930 1,915 1,890 1,570 1,290 >4 hour waits 1,665 1,581 1,191 Attendances Performance 12,598 14,159 13,919 13,940 12,744 13,002 12,149 13,900 13, % 86.4% 86.2% 86.4% 87.7% 90.1% 86.3% 88.63% 91.08% Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 >4 hour waits Attendances Performance 1,320 1,330 1,310 1,290 1, ,927 13,722 13,453 13,020 12,513 13, % 90.3% 90.3% 90.1% 90.2% 95.0% _IPR_ M2 Page 8 of 18

9 Improvement actions Following input from Hunter Healthcare, the Urgent Care improvement programme is being actioned through an Urgent Care Delivery Group chaired by the Chief Nurse; employing programme management methodology, supported by the Trust s Transformation Team; and exception reporting to Trust Management Executive, Trust Board and the Oxfordshire A&E Delivery Board The Urgent Care improvement programme is focusing on seven areas of delivery, to: Embed systematic delivery of the new front door model & hold to close account to enable flow Demand, capacity and flow Embed the Integrated Bed Management function Roll out Board Round standards and content with use of delay coding Trustwide Implement Systematic Stranded Patient Review Implement a working "Home First" or "Discharge to Assess (D2A) "model pre-winter 2018/ System-wide governance arrangements are also being revised. Local system performance During May 2018, Oxford Health s Minor Injuries Units delivered 95.56% 4 hour performance, giving an overall performance of 90.18% for the Oxfordshire A&E Delivery Board The 90% trajectory had not been achieved by Oxfordshire since April The 95% national standard has not been met by the NHS in England or by OUH since July Table 5: Oxfordshire 4 hour wait performance to May 2018 OUH + Oxford Health Apr-18 May-18 >4 hour waits - actual 1,725 1,759 Attendances - actual 14,802 17,910 Performance - trajectory 90.00% 90.0% Performance - actual 88.35% 90.18% OUH performance detail Having reduced in March and April, Emergency Department attendances rose in May and June. _IPR_ M2 Page 9 of 18

10 Figure 2: ED attendances, weeks ending 29 October June ,400 3,200 3,000 2,800 2,600 2,400 2,200 2, Emergency admissions followed a similar pattern, with a rise in late May. Figure 3: Emergency admissions (all sources), weeks ending 29 October June ,650 1,600 1,550 1,500 1,450 1,400 1,350 1,300 1, Performance has been above 85% since mid-april and above 90% during June. Figure 4: Performance against 4 hour standard, OUH, weeks ending 29 October June % 95% 90% 85% 80% 75% 70% General and acute bed occupancy (excluding day case, maternity and neonatal beds) was above 95% from October to mid-may, with a recent reduction to just above 90%. This is still higher than the 88% quoted in a recent NHS Improvement analysis suggesting that at above this level, the percentage of people seen, treated and discharged or admitted within 4 hours was adversely affected. _IPR_ M2 Page 10 of 18

11 Figure 5: % bed days occupied, OUH General and Acute beds, after safe staffing bed reductions 104% 102% 100% 98% 96% 94% 92% 90% 88% 5. Referral to Treatment Time (RTT) Performance 5.1. On 31 May 2018, 7,555 of 52,657 patients on incomplete pathways at OUH were waiting for over 18 weeks RTT Incomplete performance improved slightly from 85.13% in March to 85.25% in April and 85.65% in May against the national standard of 92%. The number of people waiting for over 18 weeks reduced slightly and while the number of >52 week waits rose above the level in March, the rate of growth was slower than expected. Component waits ,578 people completing RTT Admitted pathways in May 2018 were treated within 18 weeks (71.75%). 46 completed treatment after more than 52 weeks, down from 58 in April. 33 of the 46 were admitted to Gynaecology after more than 52 weeks ,968 patients whose RTT Non-admitted clock stopped in May 2018 were within 18 weeks (87.41%). 35 patients on the Non-admitted pathway completed treatment after more than 52 weeks, 22 in Gynaecology The number of patients on incomplete pathways having had a decision to admit and the total number of new pathways started during the month are reported nationally and shown below. Table 6: Incomplete Pathways with Decision to Admit and New Pathways by treatment function, May 2018, sorted to show largest number of New pathways first Treatment function Incomplete Pathways with a Decision to Admit New pathways Ophthalmology 1,514 1,548 Trauma & Orthopaedics 1,374 1,492 Dermatology 56 1,330 Cardiology Gynaecology 1, Gastroenterology Ear, Nose & Throat (ENT) Urology Thoracic Medicine General Surgery _IPR_ M2 Page 11 of 18

12 Treatment function Incomplete Pathways with a Decision to Admit New pathways Neurology Rheumatology Plastic Surgery Neurosurgery Geriatric Medicine Cardiothoracic Surgery General Medicine 4 37 Other 2,351 9,154 Grand Total 8,890 20,628 Specialty waits and long waits 5.6. Gynaecology s >18 week waits increased by 10 during May, much lower growth than in previous months but still adding to the challenge for 2018/ Other specialties with over 100 people waiting for over 18 weeks in May were as follows: Table 7: Specialties with >100 people waiting on incomplete pathways, May 2018 Treatment function % <18 weeks Number >18 weeks Gynaecology 66.09% 1,383 Ear, Nose & Throat (ENT) 70.88% 979 Trauma & Orthopaedics 80.38% 726 Ophthalmology 85.33% 706 Urology 86.94% 259 Plastic Surgery 78.95% 248 Dermatology 92.82% 198 Gastroenterology 91.88% 170 Cardiology 90.21% 143 Neurology 91.86% 116 Neurosurgery 80.74% 110 Trust total 85.65% 7,555 Trajectories 5.8. Waiting list and activity trajectories have been sent to NHS Improvement for 2018/ The 4 hour wait trajectory is shown above The trajectory for improvement against the 62 day cancer standard is shown below. Table 8: Cancer 62 days from urgent GP referral trajectory, 2018/19 (plan figures in shaded cells) Cancer 62 days Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Waits of >62 days: plan Waits of >62 days: actual 33.0 Total seen: plan Total seen: actual Performance %: plan 80.0% 79.4% 74.5% 74.2% 75.3% 77.5% Performance %: actual 80.0% _IPR_ M2 Page 12 of 18

13 [continued] Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Waits of >62 days: plan Waits of >62 days: actual Total seen: plan Total seen: actual Performance %: plan 81.1% 81.1% 84.2% 82.4% 85.5% 85.7% Performance %: actual For elective care waits (RTT incomplete pathways) in May: The total list size grew more than expected, there having been more clock starts in April than planned The number of people waiting for over 18 weeks reduced by 117 (1.5%), bringing it slightly below the expected level The number of >52 week waits rose above March s level. Table 9: RTT trajectories, 2018/19 (plan figures in shaded cells) Referral to Treatment Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Number of incomplete RTT pathways <=18 weeks Number of incomplete RTT pathways >18 weeks Number of incomplete RTT pathways >52 weeks Number of completed admitted RTT pathways Number of completed non-admitted RTT pathways Number of New RTT pathways (clock starts) 42,691 42,560 42,790 42,911 42,832 42,758 42,684 42,691 44,342 52,657 7,456 7,464 7,580 7,848 8,265 8,277 8,481 7,456 7,672 7, ,576 2,954 3,053 2,873 2,871 2,893 3,398 3,593 6,649 8,811 8,738 8,884 9,501 9,425 11,426 12,548 16,965 21,159 20,385 20,647 20,240 19,303 19,717 20,628 Referral to Treatment Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Year End Number of incomplete RTT pathways <=18 weeks Number of incomplete RTT pathways >18 weeks Number of incomplete RTT pathways >52 weeks 42,613 42,560 42,647 42,879 43,191 43,650 43,650 8,744 9,056 9,115 9,517 9,780 9,927 9, Number of completed admitted RTT pathways Number of completed non-admitted RTT pathways Number of New RTT pathways (clock starts) 2,936 3,018 2,368 2,534 2,528 2,653 33,257 10,287 11,427 8,584 11,065 7,805 9, ,197 21,096 21,910 16,557 21,235 18,568 21, ,984 _IPR_ M2 Page 13 of 18

14 6. Workforce 6.1. The Trust s Vacancy rate in April 2018 was 6.4%, down from 6.97% in March and above the Trust s target of 5% At the end of April, 10,760.1 whole time equivalent substantive staff were in post, down from the 10,821 in March WTE posts were vacant Sickness absence was 3.26%, above the Trust s target level of 3.2% The turnover rate reduced again to 14.09%, remaining above OUH s 12% target Costs for bank and agency staffing and financial metrics are reported in the Finance Report. 7. Additional information 7.1. Quality, Operational and Workforce indicators are shown at Appendix Benchmarking 8.1. Shown in the table below is the Trust s position on national key performance indicators for the latest period for which full data are available for the NHS in England and for Shelford Group teaching hospital trusts. 1 Table 10: Key performance indicators for OUH, NHS England and Shelford Group trusts (nationallypublished data) Note: NHS England 4 hour performance includes activity provided by non-acute Trusts. Indicator Standard England Shelford OUH % 4 hour waits from Emergency Department attendance to admission/transfer/discharge 95% May % 86.95% 88.63% <2 week waits to first appointment from urgent GP referral with suspected cancer 93% Apr % 92.57% 95.06% <2 week waits to first appointment from urgent referral with breast symptoms 93% Apr % 90.74% 93.43% First treatment within 31 days of cancer diagnosis 96% Apr % 95.71% 92.96% First cancer treatment within 62 days of urgent referral from screening service 90% Apr % 90.03% 83.33% First cancer treatment within 62 days of urgent GP referral 85% Apr % 79.39% 80% Subsequent cancer treatment in <31 days: surgery 94% Apr % 94.74% 93.14% Subsequent cancer treatment in <31 days: drugs 98% Apr % 99.08% 98.53% Subsequent cancer treatment in <31 days: radiotherapy 94% Apr % 96.95% 98.24% RTT: >52 week waits, Admitted pathways - Average vs OUH total 0 Apr RTT: >52 week waits, Non-admitted pathways - Average vs OUH total 0 Apr RTT: >52 week waits, Incomplete pathways - Average vs OUH total 0 Apr Cambridge University Hospitals, Central Manchester University Hospitals, Guy s and St Thomas, Imperial College Healthcare, King s College Hospital, Newcastle-Upon-Tyne Hospitals, OUH, Sheffield Teaching Hospitals, University Hospitals Birmingham and University College London Hospitals. _IPR_ M2 Page 14 of 18

15 Indicator Standard England Shelford OUH RTT: % <18 week waits, Admitted pathways 90% Apr % 74.73% 71.51% RTT: % <18 week waits, Incomplete pathways 92% Apr % 88.44% 85.25% RTT: % <18 week waits, Non-admitted pathways 95% Apr % 88.64% 85.28% 9. Recommendation 9.1. The Board is asked to receive the Integrated Performance Report for Month 2. Sara Randall Acting Director of Clinical Services May 2018 Report produced by Jonathan Horbury _IPR_ M2 Page 15 of 18

16 Appendix 1 Quality, Operational and Workforce indicators Quality Indicator The data quality rating has 2 components. The first component is a 5 point rating which assesses the level and nature of assurance that is available in relation to a specific set of data. The levels are described in the box below. Rating Required Evidence 1 Standard operating procedures and data definitions are in place. 2 As 1 plus: Staff recording the data have been appropriately trained. 3 As 2 plus: The department/service has undertaken its own audit. 4 As 2 plus: A corporate audit has been undertaken. As 2 plus: An independent audit has been undertaken (e.g. by the Trust's internal or external 5 auditors). The second component of the overall rating is a traffic-light rating to include the level of data quality found through any auditing / benchmarking as below Rating Quality Green Satisfactory Amber can be relied upon but minor areas for improvement identified. Red Unsatisfactory/significant areas for improvement identified. Quality Outcomes Patient Experience Standard Current Actual Summary Hospital-level Mortality Indicator** NA Sep YTD Quality Total number of deliveries NA May ,311 5 Proportion of normal deliveries 62% May % 61.6% 5 Proportion of Caesarean section deliveries 23% May % 23.3% 5 Proportion of assisted deliveries 15% May % 15.2% 5 Maternal Deaths NA May day emergency readmissions 0% May % 3.6% 5 Medication reconciliation completed within 24 hours of admission 80% May % 72.1% 4 Medication errors causing serious harm 0 May Number of CAS alerts closed having breached during the month 0 May Dementia CQUIN patients admitted who have had a dementia screen 0% May-18 73% 70.7% 4 Dementia diagnostic assessment and investigation 0% May % 100% 4 Dementia: Referral for specialist diagnosis 0% May % 100% 4 Friends & Family test response rate (Inpatients) Friends & Family test response rate (Maternity) Friends & Family test response rate (Emergency Departments) Friends & Family test % not likely to recommend (Emergency Departments) Friends & Family test % not likely to recommend (Inpatients) Friends & Family test % not likely to recommend (Maternity) Friends & Family test % likely to recommend (Emergency Departments) 0% May % 21.3% 4 0% May % 8.8% 4 0% May % 24.9% 4 NA May % 8.2% 4 NA May % 2.1% 4 NA May % 1% 4 NA May % 86.3% 4 _IPR_ M2 Page 16 of 18

17 Appendix 1 Quality Safety Standard Current Actual Friends & Family test % likely to recommend (Inpatients) NA May % 95.8% 4 Friends & Family test % likely to recommend (Maternity) NA May % 97.3% 4 Serious Incidents Requiring Investigation NA May % of Patients receiving Harm Free Care (Pressure sores, falls, C-UTI and VTE) NA May-18 94% 93.2% 3 Never Events NA May Cleaning Scores: % of inpatient areas with initial score >92% NA May % 46.9% 5 % of incidents associated with moderate harm or greater NA May % 0.6% 5 # newly acquired category 2, 3 & 4 pressure ulcers NA Apr YTD Quality Operational Standard Current Actual Standards RTT: % <18 week waits, Admitted pathways 90% May % 71.6% 4 RTT: % <18 week waits, Non-admitted pathways 95% May % 86.4% 4 RTT: % <18 week waits, Incomplete pathways 92% May % 85.5% 5 % Diagnostic waits waiting 6 weeks or more 1% May % 2.1% 3 RTT: >52 week waits, Admitted pathways 0 May RTT: >52 week waits, Incomplete pathways 0 May RTT: >52 week waits, Non-admitted pathways 0 May Emergency Department attendances NA May-18 13,900 26,049 5 % <=4 hour waits from Emergency Department attendance to admission/transfer/discharge 95% May % 87.5% 5 Last minute cancellations: % of elective admissions 0.5% May % 0.9% 3 % patients not rebooked within 28 days 0% May % 14.4% 5 Urgent cancellations second time 0 May Urgent cancellations 0 May Contract Variations Open NA May-18 3 Contract Notices Open NA May-18 0 Delayed transfers of care: number (snapshot)* 0 May Delayed transfers of care as % of occupied beds* 3.5% May % 6.3% 5 Theatre utilisation elective 80% May % 74.6% 4 Theatre utilisation emergency 70% May % 49.2% 4 Theatre utilisation total 75% May % 67.3% 4 Results endorsed within seven days NA May % 75.3% 4 % of discharge summaries sent to GP within 24 hrs 95% May % 86.1% 4 First cancer treatment within 62 days of urgent GP referral 85% Apr-18 80% 80% 4 First cancer treatment within 62 days of urgent referral from screening service 90% Apr % 83.3% 4 First treatment within 31 days of cancer diagnosis 96% Apr % 93% 4 Subsequent cancer treatment in <31 days: surgery 94% Apr % 93.1% 4 Subsequent cancer treatment in <31 days: drugs 98% Apr % 98.5% 4 Subsequent cancer treatment in <31 days: radiotherapy 94% Apr % 98.2% 4 <2 week waits to first appointment from urgent GP referral with suspected cancer 93% Apr % 95.1% 5 <2 week waits to first appointment from urgent referral with breast symptoms 93% Apr % 93.4% 5 _IPR_ M2 Page 17 of 18 YTD Quality

18 Appendix 1 Operational Standard Current Actual Same sex accommodation breaches 0 May Patients spending >=90% of time on stroke unit 85% May % 96.8% 5 YTD Quality Time to Surgery (% patients having their operation within the time specified according to their clinical 0% May % 93.6% 3 categorisation) MRSA bacteraemia 0 May Clostridium Difficile incidence 6 May % adult inpatients having VTE risk assessment 95% May % 97.1% 5 Workforce Workforce Performance Plan Current Actual Quality Vacancy rate 5% May % 3 Sickness absence** 3.2% May % 5 Turnover rate 12% May % 5 Substantive staff in post against budget 11,582.8 May-18 10, _IPR_ M2 Page 18 of 18